Analyze the event of Joyce Echaquan (JE), 37-year-old Atikamekw (Indigenous) woman, mother of seven children, who died on September 28, 2020, in the centre "hospitalier de lanaudire (hpital de joliette) saint-charles-borrome QC",northeast of Montreal(see bottom 3 links)

a) https://www.bbc.com/news/world-us-canada-58819203

b) Kestler-D'Amours, Jillian (October 6, 2020). "Indigenous Peoples Fear Racism in Hospitals. Joyce Echaquan's Death Made It Worse". VICE. Retrieved October 7, 2020. https://www.vice.com/en/article/4ayjmj/indigenous-peoples-fear-racism-in-hospitals-joyce-echaquans-death-made-it-worse

c) CTV News, Montreal. 'I know I was mean and I apologize,' Quebec nurse tells inquiry into death of Joyce Echaquan. May 20, 2021. Retrieved from: https://montreal.ctvnews.ca/i-know-i-was-mean-and-i-apologize-quebec-nurse-tells-inquiry-into-death-of-joyce-echaquan-1.5436281#

1. describes a quality failure in healthcare for this story.
2. Identify and explain/justify the failed key quality characteristic(s)
3. Discuss the causes of the failure (verified or potential) using a system thinking perspective
4. Consider the viewpoint, experience, or contribution of different stakeholders to the situation (stakeholders may include the patient and family, care providers, managers, policymakers, etc. depending on your news story)
5. Develop and justify one or more recommendations for quality improvement, including pros and cons.
6. Comment on the time and resources needed for implementation. Include suggested performance indicator(s) for monitoring progress on the key quality characteristic(s).
7. If the story offers a suggestion or solution, or describes how the problem has been addressed, you must still offer your own insights and ideas.
8. Recommendations to address the quality failure should be concrete, useful, and evidence-based.